MEDICARE: RYAN MICHAEL SUBLER O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5663	OH
2	152W00000X	Optometrist	1753DT	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5663	OTHER	OH	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000000579103	OTHER	KY	ANTHEM
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	1753DT	OTHER	KY	KENTUCKY LICENSE

General Provider Information

NPI Number	:	1568556132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN MICHAEL SUBLER O.D.

Provider Business Mailing Address
First Line	:	2174 DIXIE HWY
Second Line	:
City	:	FT MITCHELL
State	:	KY
Zip	:	41017-2902
Country	:	US
Telephone Number	:	859-341-2566
Fax Number	:	859-341-2568

Provider Business Practice Location Address
First Line	:	2174 DIXIE HWY
Second Line	:
City	:	FT MITCHELL
State	:	KY
Zip	:	41017-2902
Country	:	US
Telephone Number	:	859-341-2566
Fax Number	:	859-341-2568

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	11/04/2011

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